Healthcare Provider Details

I. General information

NPI: 1902230261
Provider Name (Legal Business Name): ALEJANDRO CUEVAS JR. COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

1040 W GRANVILLE AVE 1027
CHICAGO IL
60660-5200
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6392
  • Fax: 312-569-8050
Mailing address:
  • Phone: 773-909-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.002919
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: